The Use and Non-use of Assistive
Technology in Italy: Preliminary Data
Stefano FEDERICIa,1 and Simone BORSCI
Department of Human and Education Sciences, University of Perugia, Italy
Purpose The present pilot study aims to analyse the relationship between the
reasons of assistive technology (AT) use/non-use and the levels of user satisfaction
of Italian users/patients in order to identify which features better predict AT non-
use in the Italian Territorial Health Service Providers (THSPs) AT assessment
Method Between November 2010 and January 2011, a telephone structured
interview with open- and closed-ended questions was administrated to 430 THSP
users/patients who have received a hearing aid or a stairlift at least one year before.
Results Findings show a 25% of AT non-use and a strong correlation (p<.001)
between AT non-use and the AT users/patients’ dissatisfaction reasons –
adjustments and personalisation, safety, and comfort. Of particular interest is the
fact that users/patients tend to not use the AT if the follow-up provided by the
THSP is dissatisfactory. A strong correlation (p<.001) is also founded among the
AT satisfaction, measured by the QUEST 2.0, and some reasons of non-use; the
users, indeed, claimed that they are likely to not use the AT when they are not
satisfied by: i) The AT dimension or the weight, since it was hard to make it work
and it did not help users/patients to perform better; ii) The AT personalisation,
since they had to require more assistance than was really necessary and the AT did
not help them to achieve their goals; iii) The AT safety, since users/patients had to
spend a lot of energy using the AT, so involving other people (caregivers) who
complained about the AT; in other cases, conversely, the safety dissatisfaction was
linked to a low degree of transportability and storability of the aids; iv) The AT
simplicity of use and effectiveness, since the AT did not help users/patients to
perform better; v) The AT comfort, since AT required a lot of training and
assistance in use, did not help to achieve users/patients goals, was not comfortable
and/or was difficult to wear.
Conclusion Our data clearly show that the users’ satisfaction of AT and of service
providers are strongly correlated to the AT non-use, by suggesting that just a user-
driven process of AT assignation process, centred on the user/patient needs and
expectations might reasonably prevent the AT non-use and abandonment. The
25% of AT non-use estimated in this survey is slightly lower compared to the
range of percentages usually reported by international studies that is rated from
29% to 33%. Albeit our findings suggest that there is a lower percentage of non-
use than in other health systems, the AT non-use level remains high (about one
quarter of the ATs assigned are not used), becoming a significant economic loss
for the Italian National Health System.
Keywords. Assignation Process, Assistive Technology Assessment, Non-use and
abandonment, QUEST 2.0, User-Centred Design, Satisfaction, National Health
1 Stefano Federici email: firstname.lastname@example.org.
Everyday Technology for Independence and Care
G.J. Gelderblom et al. (Eds.)
IOS Press, 2011
© 2011 The authors and IOS Press. All rights reserved.
Assistive Technology (AT) plays a key role in facilitating the social integration and
participation of people with physical, sensory, communication, and cognitive
disabilities. The process of matching AT and person requires a well-designed and
researched sequential set of assessments administered by professionals with different
areas of expertise: the success of the matching is determined by the evaluation
protocol/model and by the skills of the multidisciplinary team members. In Italy and
other countries, matching may be provided primarily by centres for technical aids,
where a team of experts connects the person with a disability and one or more AT
In Western countries that process is characterised by two apparently opposing
models: in one of them, the most widespread in Italy and other European countries, the
person who requires an aid is considered to be a user/patient of a public health system;
in the other one, more widespread in English-speaking countries (e.g. USA), the person
with a disability may be viewed more as a customer of a private/non-national health
system. In the first case, the centre does not sell products but provides evaluation
services and aids to users/patients2; in the second case the centre for technical aids may
also sell the technological aid provided. The first model guarantees more professional
neutrality in assessing and matching technology; the second model favours user-
centred satisfaction with the product found to be a good match.
Nowadays, there are no studies that have analysed the differences in the AT
use/non-use between users of private/non-national health systems and those ones of
national health systems. On this particular issue there are no Italian assessment
published studies3. Anyway, well-known international studies on abandonment in
private/non-national health systems [1, 3, 6–9, 13, 15–19] agree on abandonment equal
to about one-third of the assigned devices. These data point out users’ widespread
dissatisfaction and frustration, probably because the user did not find facilitated his or
1. The Matching Aid and Person project
Our study presents preliminary data of a research project entitled Matching Aid and
Person (MAP), financed by the Umbria Region in 2009. The MAP project aims to
identify the percentage of AT non-use and the users’ satisfaction of AT in a national
health system in order to check the quality of health service provide by the Umbria
Region to residential citizens and prevent waste of public money. The development of
the MAP project is based on the proposals of the Umbria Regional Health Plan 2009–
2011 , in which the need of improving the service quality and the users’
satisfaction have been declared, reducing the risk of abandonment and the consequent
waste of public resources. This goal can be obtained only by improving communication
and sharing of expertise among the Territorial Health Service Providers (THSPs),
building up a best practice guide. The MAP project is structured on a “User-Centred
2 For the sake of brevity we use, from now on, just the term ‘user(s)’ instead of ‘user(s)/patient(s)’.
3 Only one unpublished Italian report on aids-use rates a 37% of abandonment. The report dated 2001,
concerning the abandonment of devices in Piedmont, indicates the percentage of abandonment without
discussing the methodology and the data recruited.
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Design” ergonomic approach suited on the biopsychosocial model of disability that
complies with the request and the need of disabled people of “nothing about us without
us” . The Umbria Region declares  a strong diversity of the care and
organisational models and of the therapeutic pathways among the THSPs, which
inevitably affects the processes for the assignment of assistive tools to disabled people.
This non-homogeneity of organisational models is associated with a lack of planning
and optimisation of the assignation process, showing also a delay in revising the
models that are not user centred. These factors, usually, show a high correlation with
the abandonment and non-use of ATs, with a consequent waste of resources and a high
users’ dissatisfaction; thus failing the aim stated in the Regional Plan to “encourage the
disabled people in the achievement of the best possible activity and participation” .
The MAP project aims to make clear not only the model of the assignment process and
specifically how much that model takes into account human needs and satisfaction, but
also the amount of AT that would be available for their reuse into the virtual cycle of
health for the benefit of other users. The MAP project pursues two main goals: i) the
first one aims to design, analyse and compare the regional THSP assignation processes
in order to build up a best practice guide able to unify and standardise the different
kinds of assignation process. The MAP team has used the ideal model of AT
assignation process described by Scherer and Federici  as criterion to compare and
evaluate each THSP of the Umbria Region. This analysis is still going on; ii) the
second one aims to analyse, by a user-centred perspective, the relation among the
assignation process, the satisfaction and the non-use of the AT. The present study is
focused on the second aim of the MAP project.
2. Materials and methods
Between November 2010 and January 2011, a telephone structured interview with
open- and closed-ended questions was administrated to 430 THSP users who have
received an AT at least one year before.
A user/patient evaluation of use of and satisfaction with AT survey questionnaire was
developed by using some of the questions of the Philips and Zhao’s Abandonment
Survey Questions , the entire Quebec User Evaluation of Satisfaction with
Assistive Technology (QUEST 2.0) [4, 5] and by creating new questions about
demographic user data and the evaluation of all services provided by the THSP. The
survey questionnaire, so composed, is a structured interview with open- and closed-
ended questions in four sections, as described in the following list:
• Anamnestic – section 1: composed of eight questions; the main goal of this section
is to identify who answers the questions (the user, the caregiver, or the user and the
caregiver together), and the kind of AT.
• National services evaluation – section 2: composed of five questions; this section
aims to obtain a global evaluation of the i) THSP office for assignation; ii) general
health care services provided by the THSP; iii) the time perceived by users spent
obtaining the AT; iv) the number of steps perceived by users obtaining the AT; v)
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the bureaucracy perceived by users in the process. Each question is a 5-point likert
scale from 1 (not satisfied at all) to 5 (very satisfied).
• Users’ satisfaction with AT – section 3: composed of a QUEST Italian version 2.0
[4, 5]. The QUEST can be used as a self-administration questionnaire or as an
interview, with the response categories ranging from 1 (not satisfied at all) to 5
(very satisfied). The QUEST scores can be analysed by three scales: Device (from
Q1 to Q8), Services (from Q9 to Q12), and a Total score. All scores are calculated
by summing and then averaging valid responses to assigned items [4, 5].
• AT non-use – section 4: composed of 17 questions (from A1 to A17), this section
is administrated only to the users that declared the abandonment of the AT. For the
interview on the abandonment, we selected among the 30 questions used in the
study of Philips and Zhao , the 23 that those authors have indicated as the
questions that have obtained the most number of answers, in their study, by the
users. We also excluded six questions indicated by Philips and Zhao from our
survey on abandonment, because they are contained (implicitly or explicitly) in
other sections of the global survey (Table 2). All these questions have three
options of answers: Yes, No, I do not know  except for A15 (How long
have/did you use AT?) that is expressed by four time options.
The survey questionnaire was administered through a telephone interview to 430 THSP
users who have received an AT at least one year before. The list of participants was
provided by the THSP subject to the agreement between the Department of Health of
the Umbria Region and the Department of Human and Education Science of the
University of Perugia.
A database of 430 participants was provided by the THSP with users who have
obtained a hearing aid (HA) (355) or a stairlift (SL) (75) at least one year before the
survey. One hundred and four participants (25 male, 79 female) accepted to respond to
a telephone interview with a response rate of 24.1%, of whom 81 (77.9%) obtained a
HA and 23 (22.1%) have obtained a SL. Data about AT users was provided via
telephone by the users themselves alone (25%; M of AT users age=72.5; SD=16.2); or
by the user with the help of third-party, e.g. family members or caregivers (2%; M of
AT users age=77.3; SD=12.7); or third-party alone, e.g. family members or caregivers
(73%; M of AT users age = 78.5; SD=12.1).
2.3. Data analysis
Initially, descriptive analyses (Mean [M], Standard deviation [SD]) were conducted to
explore the features of the sample. Psychometric properties of reliability and validity in
the QUEST 2.0 Italian version were then assessed. The correlations among the
subscales of the QUEST and the scores of the section 2 (national services evaluation)
and the section 4 (non-use of AT) of the survey questionnaire were calculated by
Pearson’s correlation coefficient. A sufficiently high score indicates that users’
satisfaction correlates with AT non-use reasons. Data were processed using the
software IBM® PAWS Statistics18.
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3.1. Users’ evaluation of national service and user satisfaction
The users’ evaluation of the national service (survey section 2) shows that 70.6% of the
users are satisfied with the service provided by the HTSP (51.9% quite satisfied, 11.5%
very satisfied), albeit the 29.4% of the participants claimed that they are more or less
satisfied 11.1%, not very satisfied 12.5%, or not satisfied at all 5.8%. The analysis of
users’ satisfaction with AT (section 3) obtained by the administration of the QUEST’s
total scores shows that the global score for the HAs’ satisfaction (M=4.08, SD=.81) is
less than the satisfaction of the users that have received a SL (M=4.43, SD=.87).The
level of users’ satisfaction that have obtained HAs is decreased due to low scores (but
sufficient) of satisfaction for the services provided by the HTSP (M=3.19, SD=.86).
The different levels of satisfaction are clearer when we analyse the satisfaction
percentage declared by the users in each question of the QUEST. Overall, users have a
good level of device satisfaction (from Q1 to Q8), with some problems with the safety
(Q4) of the AT, particularly for HA users who declared a 38.3% of dissatisfaction,
while SL users are dissatisfied for 17.4% of the cases. A durability problem is evident
for the HA users who are dissatisfied for 19.8% of the cases (Q5); at the same time,
these users show a high dissatisfaction also for the comfort (Q7) and for the
effectiveness (Q8) of the AT. A higher degree of dissatisfaction is declared by the HA
users than the SL ones: 21% of the HA users are dissatisfied with the comfort and 37%
with the effectiveness, while the SL users declared a dissatisfaction of 17.4% for the
comfort and 13% for the effectiveness. The analysis of the QUEST’s questions from
Q9 to Q12, concerns the users’ satisfaction of the service offered by the THSP in
providing the AT. This analysis shows that there is a very high degree of dissatisfaction
with the THSP service delivery (Q9), particularly 83% of users declared that the
problem is the time spent obtaining the AT (25.9% for HA users, and 34.8% for SL
ones). A warning level of users’ dissatisfaction also concerns both the professional
service (Q11) and the follow-up (Q12) which respectively have obtained a
dissatisfaction degree equal to 14.8% (HA) and 13% (SL) for the professional service,
and 13.6% (HA) and 21.7% (SL) for the follow-up.
The correlation between national service evaluation (survey section 2) and the
users’ satisfaction with AT (survey section 3) is analysed by the Pearson’s coefficient.
This analysis shows a good correlation between the national service evaluation and the
following questions that composed the QUEST’s device satisfaction scale: the weight
of the aids (Q2; r=.201, p<.05), the easiness of adjustment of the aids (Q3; r=.206,
p<.001), the simplicity of use (Q6; r=.206, p<.05), the comfort (Q7; r=.245 p<.05) and
the effectiveness of the aid (Q8; r=.239, p<.05.).
At the same time a very strong correlation (p<.001) is shown between the
evaluation expressed by users in the section 2 and all the questions that composed the
scale service of QUEST (from Q9 to Q12).
3.2. Users’ satisfaction and users’ non-use
The analysis of the non-use of AT (section 4) shows that there are 25% of AT non-use
in the THSP and a strong inverse correlation among the users’ AT non-use and section
3 (Table 1).
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Table 1. Pearson’s correlation index between the non-use of AT (section 4) and the QUEST scales ‘Device’
and ‘Service’ (survey section 3). Significant correlations are found within the scale ‘Device’ – Adjustments
(Q3), Safety (Q4), Comfort (Q7) – and ‘Service’ – Follow-up (Q12).
Q3 Q4 Q7 Q12
AT Non-use -.194* -.275** -.207* -.225*
*The correlation is significant at level .05; **The correlation is significant at level .01.
The results show that unless the user is satisfied with AT adjustment (Q3), safety
(Q4) and comfort (Q7), the more likely he or she does not use technology. At the same
time an important role in the use/non-use of AT is played by follow-up service. The
percentages of the different reasons that contribute to the AT’s non-use (survey section
4), are shown in Table 2, excluding from the analysis the question A15 (How long
have/did you use it?) which provides answers in the scale of time.
Table 2. Frequencies of users’ responses to the optional survey on the reasons of AT non-use.
Yes No I do not know
A1 – Was it easy to obtain from the supplier? 65.4% 30.8% 3.8%
A2 – Did the installation/assembly require a lot of work? 69.3% 26.9% 3.8%
A3 – Did you require more than 2 hours of training in AT use? 46.2% 46.2% 7.6%
A4 – Is/was it easy to make AT work? 46.2% 53.8%
A5 – Do you require assistance in using the device? 69.2% 30.8%
A6 – Did/does the AT always work? 42.4% 53.8% 3.8%
A7 – Did/does the AT help you perform better 38.5% 61.5%
A8 – Was/is the AT comfortable? 38.5% 57.7% 3.8%
A9 – Was/is the AT safe to use? 53.8% 46.2%
A10 – Did/does it demand a lot of energy/time to use (self)? 27% 61.5% 11.5%
A11 – Did/does it demand a lot of energy/time to use (others)? 15.4% 65.4% 19.2%
A12 – Did/do others complain about the item? 15.4% 76.9% 7.7%
A13 – Was/is it easily transportable? 80.8% 15.4% 3.8%
A14 – Was/is it easily stored? 80.8% 15.4% 3.8%
A16 – Did/does it wear well? 34.6% 50% 15.4%
A17 – Have your needs changed? 42.3% 57.7%
A great level of correlation is shown among the questions of QUEST (survey
section 3) and the reasons of non-use gathered by section 4 (Table 3).
Table 3. Pearson’s correlation index among the QUEST items (survey section 3) and the reasons of AT non-
use (survey section 4). Seven items of QUEST (Q1, Dimension of aid; Q2, Weight of aid; Q3 Adjustments;
Q4, Safety; Q6, Simplicity of use; Q7, Comfort; Q8, Effectiveness), show a correlation with one or more of
the following reasons of AT non-use: A3 – Did you require more than 2 hours of training in AT use? A4 –
Is/was it easy to make AT work? A5 – Do you require assistance in using the device? A7 – Did/does the AT
help you perform better? A8 – Was/is the AT comfortable? A11 – Did/does it demand a lot of energy/time to
use (others)? A12 – Did/do others complain about the item? A13 – Was/is it easily transportable? A14 –
Was/is it easily stored? A16 – Did/does it wear well?
Q1 Q2 Q3 Q4 Q6 Q7 Q8
A5 -.490* -.423*
A7 -.802** -.802** -.415* -.414* -.436* -.610**
*The correlation is significant at level .05; **The correlation is significant at level .01.
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Our data clearly show that a good assignation process, favoured by a user-centred
design and focused on the users’ needs is strictly related to AT user satisfaction and aid
use/non-use. The relation between the satisfaction and the reasons of non-use is very
strong, as it is shown in Table 2. The users claimed that they are likely to not use the
AT when they are not satisfied with the following AT features:
• Dimension (Q1) or weight (Q2): in this case users claim that it is hard to make AT
work (A4) and/or AT does not help them to perform better (A7).
• Personalisation (Q3): in this case users have to require more assistance to use the
AT than is really necessary (A5) and, also, the AT does not help them to achieve
their goals (A7).
• Safety (Q4): in this case users declare to spend a lot of energy in order to use the
AT assigned (A11), involving other people (caregivers) and, in their turn, also the
caregivers themselves complain about the AT assigned (A12). At the same time,
the safety dissatisfaction could be also linked to a low degree of transportability
(A13) and storability of the aids (A14).
• Simplicity of use (Q6) and effectiveness (Q8): in this case users affirm that the AT
does not help them to perform better (A7).
• Comfort (Q7): in this case users complain about a lot of training (A3) and
assistance in use (A5) required for the AT use. Moreover, the AT does not help
users to perform better (A7), it is not comfortable (A8) and/or difficult to wear
Our preliminary data shows an abandonment of 25% of AT. This percentage is lower
than the percentages usually reported in other studies [1, 3, 6–10, 13, 15–19] that range
from 29% to 33%. However, until now, the data are limited to just one of the four
THSPs of Umbria Region and to specific kinds of AT (i.e. HAs and SLs). As Philips
and Zhao, we adopted: “a stringent definition of abandonment that described only one
outcome of a ‘person-technology’ interface. Changes in device brands that do not
represent changes in device categories were not accounted for even though those
changes may have been due to dissatisfaction with the original device” . However
we extend the perspective of analysis introducing both, an instrument for analysing the
AT and service users’ satisfaction (QUEST 2.0) and for the evaluation of the global
service provided by the Italian National Health System in the territory (survey section
2). By using the Philips and Zhao word “This study’s findings suggest that services
designed to involve consumers and accommodate long term technology needs will
enhance consumer satisfaction with AT and reduce device abandonment” . In this
sense our study remarks that just a user-driven process of AT assignation, centred on
the user needs and expectations might reasonably prevent the AT non-use and
Globally, users of public/national health systems declared a good satisfaction level
of the THSP work. However, users complain about three main problems that affect the
THSP service: the long delay in the delivery of the AT assigned, the lack of a follow-
up, and a low professional profile in the technical support. Our results clearly show that
the satisfaction of the users in AT use is linked to the satisfaction of the THSP; indeed,
the correlation analysis shows that the more the users are satisfied about some AT
S.Federiciand S.Borsci/ The Use and Non-Use of Assistive Technology in Italy 985
features (e.g. weight, easiness of adjustments, simplicity of use, comfort and
effectiveness) the more they are satisfied with the THSP service. At the same time our
findings underline that the less users are satisfied with some AT features (e.g.
adjustment, safety and comfort) the more likely they do not use technology.
The percentage of AT non-use found in this study shows that one quarter of the
assigned AT are not used by the users. Even if this percentage of abandonment or non-
use shows a lower rate compared to findings of international studies, this amount is still
high, becoming a significant economic loss for the Italian National Health System.
Funding for the Match Aid & Person project has been provided by the Sanity and
Social Services Department of the Umbria Region in 2009 (DGR 1318/09).
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